Is albumin recommended in patients with hypotension, cirrhosis, and hepatic encephalopathy?

Albumin Use in Cirrhotic Patients with Hypotension and Hepatic Encephalopathy

In patients with cirrhosis, hypotension, and hepatic encephalopathy, albumin administration is recommended for the hypotension if it is sepsis-induced, but the evidence for treating hepatic encephalopathy remains uncertain and current guidelines abstain from making a definitive recommendation for this specific combination.

Addressing the Hypotension Component

Sepsis-Induced Hypotension

• Use 5% albumin over normal saline for cirrhotic patients with sepsis-induced hypotension, as this improves short-term survival (43.5% vs 38.3% at 1 week, p=0.03) 1
• A 2024 randomized trial demonstrated albumin's superiority in achieving mean arterial pressure >65 mmHg at 3 hours (62% vs 22%, p<0.001) compared to crystalloids 2
• Albumin provides faster hemodynamic improvement and lactate clearance than plasmalyte in sepsis-induced hypotension 2

Critical Safety Consideration for 20% Albumin

• Monitor extremely closely for pulmonary complications when using 20% albumin, as treatment had to be discontinued in 22% of patients due to adverse effects, primarily pulmonary edema 2
• The 2024 ALPS trial showed that while 20% albumin improved hemodynamics faster, it caused significantly more pulmonary complications and did not improve 28-day mortality (58% vs 62%, p=0.57) 2
• Consider using 5% albumin or balanced crystalloids (lactated Ringer's) as safer alternatives for initial resuscitation 1

Non-Septic Hypotension

• For hypotension not related to sepsis, balanced crystalloids are preferred for initial resuscitation 1
• The 2024 International Collaboration for Transfusion Medicine Guidelines found no improvement in patient-important outcomes when albumin was used for general volume replacement in critically ill cirrhotic patients 3

Addressing the Hepatic Encephalopathy Component

The Evidence Dilemma

The guideline panel faced contradictory evidence and explicitly abstained from making a recommendation for albumin use in hepatic encephalopathy due to uncertainty 3. Here's why:

Supporting Evidence (Older, Smaller Studies):

• A 2021 meta-analysis of two small RCTs (N=176) showed albumin reduced hepatic encephalopathy (RR 0.60,95% CI 0.38-0.95) and mortality (RR 0.54,95% CI 0.33-0.90) 3, 4
• One trial showed 75% complete resolution with albumin-lactulose versus 53% with lactulose alone (p=0.03) at day 10 3, 1
• The dosing used was 1.5 g/kg on day 1 followed by 1.0 g/kg on day 3, combined with lactulose 1

Contradicting Evidence (More Recent, Larger Study):

• The subsequent large ATTIRE trial (N=149 patients with hepatic encephalopathy) found no improvement in the composite endpoint of new infections, kidney dysfunction, or death (adjusted OR 0.91,95% CI 0.44-1.86) 3
• This trial also demonstrated increased rates of pulmonary edema with albumin administration 3

Practical Approach Given the Uncertainty

Given the conflicting evidence and the guideline panel's abstention, prioritize standard hepatic encephalopathy treatment with lactulose and rifaximin while addressing the hypotension as outlined above 3. If you choose to use albumin for hepatic encephalopathy:

• Consider it only in acute hepatic encephalopathy with concurrent sepsis-induced hypotension (where albumin is already indicated for the hypotension) 1
• Use the dose of 1.5 g/kg on day 1 and 1.0 g/kg on day 3, combined with lactulose 1
• Monitor aggressively for volume overload and pulmonary edema 3, 2

Critical Monitoring Algorithm

Before Administration:

• Assess cardiac and pulmonary function via echocardiography 1
• Evaluate for signs of volume overload or heart failure 1

During and After Administration:

• Monitor respiratory rate and oxygen saturation continuously 1
• Watch for respiratory distress or declining oxygen saturation 1
• Immediately discontinue albumin if pulmonary edema develops 1, 5
• Use echocardiography to guide fluid management 1

Common Pitfalls to Avoid

1. Using 20% albumin without intensive monitoring: This formulation has significantly higher rates of pulmonary complications 2
2. Administering albumin for hypoalbuminemia correction alone: The 2024 guidelines explicitly recommend against this practice in decompensated cirrhosis (adjusted OR 0.98,95% CI 0.71-1.33 for benefit) 3
3. Assuming albumin is universally beneficial in cirrhosis: The ATTIRE trial showed increased serious adverse events, primarily pulmonary edema, when targeting albumin levels >30 g/L 3
4. Ignoring the increased capillary permeability in septic cirrhotic patients: These patients are at particularly high risk for albumin-induced pulmonary edema 1

Bottom Line for Clinical Practice

For your specific patient with cirrhosis, hypotension, and hepatic encephalopathy: Use albumin if the hypotension is sepsis-induced (preferably 5% albumin), but do not rely on it to treat the hepatic encephalopathy—treat that with standard lactulose-based therapy. Monitor aggressively for pulmonary complications, as this patient population is at high risk for volume overload 3, 1, 2.